integrating palliative care in oncology practice · objectives 1) define palliative care and its...
TRANSCRIPT
Rebecca KirchEVP Healthcare Quality and Value
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Integrating Palliative Care in Oncology Practice: Building Better Bridges to Quality of Life
COA Annual Community Oncology Conference
April 2018
Disclosure
Rebecca Kirch is a consulting advisor tothe Center to Advance Palliative Care.
Objectives
1) Define palliative care and its impact on quality of life and person-centered care delivery
2) List key research studies that have demonstrated the benefits of palliative care in oncology
3) Explain the value proposition for palliative care in the triple aim context of better health and better care at lower cost
4) Identify the critical components of palliative care in delivery of high quality oncology services
5) Locate at least three available resources for improving core palliative care competencies that support person-centered care
6) Describe at least five action steps that support person-centered and family-focused quality oncology care improvement in this era of value-based reform
Modern medicine has helped thousands of seriously ill adults and children live longer lives.
Value-based care demands that we bring the same level of attention to the qualityof these longer lives.
Quality is our Context
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Today’s session emphasis• Science behind palliative care integration
• Words to use and integration approaches in practice
• Communication resources available
• Advocacy and Action steps we can all pursue
Pressure Points: Better Patient Experience at Lower Cost
Demand for value-based care is growing. Success depends on:
Attention to the Patient Experience
• Assessment and treatment of pain, depression, other symptoms and suffering patients/families identify as important
• Caregiver needs for information and support
Efficient Health Services Utilization
• Reduced ED and hospital use
• Keeping costs below target
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Amy
Good Health
Quality Treatment
Good QOL
“I don’t want longer length of life if it is a bad time.I want a good time for as long as possible.”
Berman A, Living Life In My Own Way—And Dying That Way As Well (Health Affairs April 2012)
Berman A, The Next Chapter: Amy Berman Reflects on ‘Living Life in My Own Way’(Health Affairs Blog May 2014)
“Palliative care is the best friend of the seriously ill.”
Palliative Care = better quality care
• Medical care focused on quality of life for the patient and family that provides relief from the symptoms and stresses of serious illness
• Appropriate at any age and any stage
• Provided along with curative treatment as an added layer of support
Consumer-tested description from CAPC/ACS public opinion research
What Hospital and Health System Leaders SayTop Challenges They Face: • Insurance Reimbursement• Patient Satisfaction• Hiring and Maintaining Staff
Benefits of having a PC program:• Improves QOL and support for
patient and family• Improves doctor and staff
satisfaction
Education and resource needs:
• Patients need to be made aware that PC exists as an option
• Providers need PC training and help understanding that people benefit from PC earlier in treatment than they might think
• Executives need to understand the value and benefits of PC for their institution
Source: CAPC 2017 market research among health system leaders across the US about providing care for seriously ill patients
Palliative Care = Triple Aim Solution
• Improves quality of life✓Relieves pain, distress, uncertainty
✓Addresses patient and family goals
• Strengthens communication, decision-making and family satisfaction/well-being
• Coordinates medical and practical needs across care settings and care transitions
• Reduces resource utilization and costs by matching treatment to patient and family goals
• Makes it more likely that adults, children and families have fun and meaning
Early palliative care delivers a better patient experience
•Dramatic reduction in depression (16% vs. 38%)
•Higher quality of life score (98.0% vs. 91.5%)
• Increased survival by 2.7 monthsTemel JD, Greer JA, Muzikansky A, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer, New England Journal of Medicine. 2010;363(8):733-742.
Also shown to improve caregiver experienceKavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis. JAMA. 2016;316(20):2104-2114.
El-Jawahri A, Greer JA, Pirl WF, et al. Effects of Early Integrated Palliative Care on Caregivers of Patients with Lung and Gastrointestinal Cancer: A Randomized Clinical Trial. The Oncologist. 2017.
What’s in the syringe?
Journal of Clinical Oncology 36, no. 11 (April 2018) 1096-1102
• Coping: Improved QOL and reduced depression symptoms
• Treatment Decisions: Reduced chemotherapy initiation and hospitalization in 60 days before death
• Advance Care Planning: Increased likelihood of using hospice
These are key elements of early PC to enable dissemination of the integrated care model.
Three elements of PC visit focus associated with improved patient outcomes:
Early palliative care delivers cost savings
•Early palliative care shifts expenditures from inpatient to outpatient and hospice
•Over $2,500 saved per case
Greer JA, Tramontano AC, McMahon PM, et al. Cost Analysis of a Randomized Trial of Early Palliative Care in Patients with Metastatic Nonsmall-Cell Lung Cancer. J Palliat Med. 2016;19(8):842-848.
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Early palliative care controls utilization
Scibetta C, Kerr K, McGuire J, Rabow MW. The Costs of Waiting: Implications of the Timing of Palliative Care Consultation among a Cohort of Decedents at a Comprehensive Cancer Center. J Palliat Med. 2016;19(1):69-75.
Early versus late referral to palliative care for decedents:
• Reduced hospital admissions (33% vs. 66%)
• Reduced ED use (34% vs. 54%)
• Reduced ICU use (5% vs. 20%)
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People WANT Palliative Care
Data from CAPC/ACS Public Opinion Strategies national survey of 800 adults conducted June 2011. www.capc.org
Very Likely to Want
Palliative Care
Somewhat Likely to
Want Palliative
Care
Neutral or Unlikely
Once Informed, People Are:
Key consumer research takeaways:
▪Palliative care is a relative unknown among consumers (92% really don’t know what it is)
▪People understand and want palliative care if we use their words to define & describe it
▪Use consistent QOL messages proven to work and they will stick
“It’s like when you’re filling in concrete.
The transplanters are the people who put the layer down, then palliative care are the people who go after and fill the holes, so the whole thing doesn’t start to crumble.
But if it does start to crumble they’re the people who actually go with the hard hats and fix it.”
- Gwen Lorimer, The New Yorker Jan 2014
Palliative care = quality care
“If you ever have any doubt about the value of this program, believe me, there are families that I’ve met, and two minutes into that conversation, for you to say there’s not value in palliative care would be impossible.”
- Akron Children’s Hospital CEO Bill Considine
Palliative care improves:
• Quality of life and the quality of how people are living
• Care coordination over the course of illness
QOL Lifeline
• Communication about what matters most to patients and families that helps match treatment with their values
• Quality of care that helps patients and families avoid 911 calls, ED visits, repeated lengthy hospitalizations
Who delivers it? All Clinicians
Quill TE, Abernethy AP. Generalist plus Specialist Palliative Care — Creating a More Sustainable Model. New England Journal of Medicine. 2013;368(13):1173-1175.
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Palliative Care Specialists Specialized team consultation/co-management:
High ED use
Complex decisions
Challenging symptoms
Poor Adherence
High caregiver distress
Generalist palliative care: Everyone
Basic symptom management, communication and coordination to align treatment with goals and support quality of life
Evidence-based skills training is readily available for all oncology clinicians
These are the patientsthat would benefit frompalliative care consultsand/or co-management
Payment for palliative care services
In the meantime…
• Hospitals bill for inpatient days under traditional Medicare/Medicaid or commercial insurance
• Physicians (and APNs in some states) bill for consultation services under Medicare Part B and commercial insurance
• Direct funds and philanthropy cover the gaps
• Medicare has 2 advance care planning codeshttps://www.capc.org/payers/palliative-care-payer-provider-toolkit/
Two palliative care APMs recently recommended by PTAC advisory panel to HHS
The Oncology Care Model
OCM “enhanced services” require 13-point care plan that communicates:
• Treatment benefits and harms, toxicities, short term and late effects
• QOL and likely experience with treatment
• Who will take responsibility for specific aspects of patient’s care
OCM participation means oncology teams must conduct:
• Expert and effective pain and symptom management (the #1 reason for 911 calls);
• Skilled communication about achievable and affordable priorities for care
• Coordination over time and across settings
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Palliative care integration in oncology is essential for improved quality care.
Many practices already have access to palliative care specialists
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www.getpalliativecare.org
Some cancer centers are embedding palliative care teams into their practice
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Palliative Care Improves Value
Improves Quality
• Symptoms
• Quality of life
• Family satisfaction
• Family bereavement outcomes
• Clinician satisfaction
• May improve length of lifeShrinks avoidable spending
• Need for hospital, ICU, ED
• Hospital costs
• 30 day readmissions
• Hospitality mortality
• Labs, imaging, pharmaceuticals
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Oncology Palliative Care
Optimal Care: Survival with QOL
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Palliative care needs of all adults and children confronting cancer must be assessed and addressed in all care settings –regardless of disease stage or prognosis.
Even cancer patients with relatively good prognoses have
significant symptom burdens in physical, emotional, and existential domains
Journal of Palliative Medicine December 2015
Disease-directed cancer therapies
Palliative care
Psychosocial support
Impairment driven rehab
Other integrative therapies for wellness
SKILLED COMMUNICATION
Extend survival with high quality of life
Optimize longevity and well-being
Integrating the patient and caregiver voice into serious illness care: Proceedings of a Workshop. National Academies of Sciences Engineering and Medicine 2017. www.nap.edu.
Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services. Silver J, Raj
V, Fu J, Wisotzky E, Robinson Smith S, Kirch R. Supportive Care in Cancer 2015
Early Specialty Palliative Care — Translating Data in Oncology into Practice. Parikh RB, Kirch RA, Smith TJ, Temel JS. New England Journal of Medicine 2013
Advancing a Quality-of-Life Agenda in Cancer Advocacy: Beyond the War Metaphor. Parikh R, Kirch R, Brawley O. JAMA Oncology 2015
Advancing a comprehensive cancer care agenda for children and their families: Institute of Medicine
Workshop highlights and next steps. Kirch R, Reaman G, Feudtner C, et al. CA: A Cancer Journal for Clinicians 2016
Consensus on quality care elements care
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Institute of Medicine Quality Cancer Care Report:Charting a New Course for a Health System in Crisis (2013)
QOL care
ASCO 2016 Clinical Practice Guidelines
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Inpatients and outpatients with advanced cancer should receive dedicated palliative care services early in the disease course concurrent with active treatment.
Referral of patients to interdisciplinary palliative care teams is optimal and services may complement existing programs.
Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.
https://www.asco.org/practice-guidelines/quality-guidelines/guidelines/supportive-care-and-treatment-related-issues#/9671
Pediatric Patients
AAP Policy Statement 2013 also called for pediatric palliative care as an essential aspect of providing optimal treatment from diagnosis and continuing along course of care
But…
• Only 58% of COG member institutions have a pediatric palliative care service
• Nearly one-third of children’s hospitals still don’t have a palliative care program
• Most pediatric palliative care programs are understaffed
(Feudtner et al. Pediatrics 2013)
ASCO and AAHPM Joint StatementGuidance on Defining and Providing High-Quality Palliative Care Services in Oncology
Oncologists: All Patients
Assess and manage symptom burden
Explain prognosis
Ask about what’s most important
Review all treatment options
Palliative Care Consults: Complex Patients
Co-manage complex or intractable symptoms
Help clarify priorities for care
Address caregiver distress, social challenges
Maximize quality of life
Hospice Referral
Discuss when disease progresses despite treatment
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http://ascopubs.org/doi/full/10.1200/JOP.2016.010686
Mission Critical: Quality of Life and Person-Centered Communication
• With the doctors there was not really much balance as far as quality of life.
• They were very concerned with curing - it was his cancer they wanted to treat and not him.
• The nurses, they saw my dad. And they saw a family who was grieving and needed help.
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“I think it is very important for everybody to be honest with families, to tell you what is going to happen. This is how you can prepare.
Then your hope can change along with the circumstances.”
Palliative care and quality of life: patient-centered care case study.Kirch R. Archives of Internal Medicine 2012; 172(15):1170-1172.
Patient Advocate Foundation Roadmap to Consumer Clarity Report Case Study 2017. www.npaf.org
Patient and Family Priorities
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IOM 2013 Quality Cancer Care report: Charting a New Course for a System in CrisisAlston C, Paget L, Halvorson GC, et al., Communicating with patients on health care evidence: Discussion paper (2012)https://nam.edu/wp-content/uploads/2015/06/VSRT-Evidence.pdf
What people want (n=1068 adults):
• Listen to me
• Tell full truth
• Tell about risks
• Explain impact on QOL
• Understand my goals and concerns
Patient Advocate Foundation’s 2017Roadmap to Consumer Clarity onHealth Care Decision Making
VIEW ROADMAP REPORT AT https://www.npaf.org/roadmap/
Making Person-Centered Care HappenKnowing what’s important to patients and caregivers is paramount.
They want:
• Understandable, accurate health care information
• Family-focused care that uses skilled communication to engage them as partners
• Care and services aligned with their priorities and preferences
What matters to them is essential expertise they must be invited to bring to the table continuously.
Skilled Communication
Person-centered and Family-focused Care
WHAT MATTERS
• Support QOL and function
• Minimize burdens on family
• Address concerns about role changes and illness stigma
• Acknowledge uncertainty, hopes, fears, and spiritual concerns
WHAT’S THE MATTER
• Diagnosis
• Disease-directed treatment
• Manage side effects
• Coordinate care and transitions
• Evaluate outcomes
Rebalancing the Health System
Person-Centered Communication is Palliative Care’s Core Competency
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QOL Conversation Cues:
1. Tell me about you as a person
2. How do you like to get medical
information?
3. What is your understanding of
your situation now?
4. What is important to you?
5. What are you hoping for and
what are your worries?
6. Where do you find your strength
and comfort?
Always Ask TattooApply here
Consensus Now: QOL communication is essential in quality care planning and treatment part of quality care
Recommendation: Provide understandable information about cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and costs
Recommendation: Professional education for cancer programs should prioritize formal clinical communication skills development training
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Explainaholicism
Expect Emotion.TIP: If you feel compelled to respond with a fact, hit your pause button
Empathy
Anthony Back, MD
Practicing empathy works!
Rx: This book is a superb starter course to hone clinical communication skills for handling tough conversations
Good communicators draw on a large repertoire of learned skills to collect essential person-centered data about their patient’s values, goals and concerns.
These skills take practice to master.
Good communication promotes patient trust plus professional resilience that prevents burnout.
.High-quality, evidence based communication training is ready
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✓ Talking maps and podcasts vitaltalk.org
✓ iPhone/Android APPS VitalTalk and VitalTips
✓ Online course and in-person training vitaltalk.org/courses
✓ VitalTALK online communication curriculum is also available through CAPC Central at capc.org
CAPC provides hospitals, health systems, hospices, payers, and other health care organizations with the tools, training, technical assistance, and metrics needed to support the successful implementation of palliative care.
Over 1,000 hospitals and health systems are members and all staff have access to CAPC resources
• Communication skills• Pain Management• Symptom Management
www.capc.org
Center to Advance Palliative Care (CAPC)
Professional Webinar Series 2017
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Palliative Care, Value-Based Payment and the Patient Experience: A Guide for a Changing WorldFeaturing Diane Meier, MD, Director, Center to Advance Palliative Care
Matching Treatments to Values: Sharpening Person-Centered Communication Skills and StrategiesFeaturing Anthony Back, MD, Professor of Medicine at the University of Washington and Fred Hutchinson Cancer Research Center
Solutions in a Time of Crisis: Ensuring Safe and Effective Pain Relief through Good Policy and PracticeFeaturing Judith Paice, PhD, RN of Northwestern University and Robert H Lurie Comprehensive Cancer Center and Robert Twillman, PhD, FAPM of the Academy of Integrative Pain Management
Recordings available at: www.npaf.org/our-work/webinars/
Online patient decision support tool at: prepareforyourcare.org
Online video library and tools at: courageousparentsnetwork.org
Consumer-oriented information at: getpalliativecare.org
Tools for your patients
Rx: Playing this game creates a safe place to talk about what’s important to people, transforming anxiety about dying into conversations about living
Good Conversations Start with “Hello”…• Patients• Clinicians/staff• Community Education
Access info at http://www.commonpractice.com/hello
Give People the Words to Use
Trending: Palliative Care as Standard of Practice“Palliative care is the entity that comes forward and asks the right questions. I’m not saying other staff won’t come to the fore and make everything ok, but boy, palliative care is an insurance policy and I don’t know how a hospital would meet their mission without having that service.”
– CEO Bill Considine, Akron Children’s Hospital
“There’s a strong rationale for hospital investment in PPC because it fosters effective communication, enhances quality care, and improves the patient and family experience – this really is an investment in delivering high quality care.” – CHOP Physician-in-Chief Joe St. Geme
“Regardless of whether it generates a lot of revenue, it’s just mission critical. Families need it, critically ill children, children with chronic disease, children with complex medical problems, they all need it. It’s absolutely essential to their recovery, to their health, in some cases to death with dignity. It’s one of those ‘gotta do’ things. It’s not optional. It’s mandatory.
– Texas Children’s Department Chair Mark Kline
• Increase awareness of PC benefits for public, professionals and policymakers
•Expand education for health care workforce
•Provide adequate training and support for care team - including family caregivers
•Align reimbursement and insurance design to match patient/family needs
• Improve accountability for quality
•Boost research investment to build the evidence base
DE Meier, AL Back, A Berman, SD Block, JM Corrigan, RS Morrison. A National Strategy for Palliative Care. Health Affairs. 2017;36(7):1265-1273.
National Strategy for Boosting PC Access What will it take?
Treating the person beyond the disease
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Patient QOL Coalition Activity
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State palliative care legislation• State expert advisory council
• Information and resources for consumers and clinicians
Palliative Care National Legislative Agenda
Palliative Care & Hospice Education and Training Act (PCHETA) H.R. 1676 & S. 693• Promote education and research• Increase public awareness• Support development of faculty careers in academic palliative medicine• Increase palliative care faculty in medical, nursing, social work schools
Educate. Energize. Engage.Achievable Actions to Deliver Real Value Ask what matters to patients and caregivers at key points and
document those priorities so they get the quality care they want
Talk about palliative care as standard of practice for all audiences –it’s an added layer of support for maximizing QOL and quality care
Get to know palliative care colleagues at your institution
Check out the noted resources and tell colleagues about them to help boost person-centered communication skills and care
Prioritize person-centered communication and practice empathy –try the “Always Ask” tattoo
Commit to skills development training ✓ Register for the 4/19 Communication Skills Pathfinder webinar✓ Find out if your institution has a CAPC membership to access
online curricula✓ Subscribe to VITALtalk✓ Play “Hello” with your family/friends/team
